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Inspection on 12/05/05 for Copperfield House

Also see our care home review for Copperfield House for more information

This inspection was carried out on 12th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a group of staff who are well motivated and are keen to maintain good standards of care. Service users spoken to felt staff have built good relationships with them and work hard to improve their quality of life.

What has improved since the last inspection?

The home has improved the care planning process. The needs of service users are assessed prior to moving to the home. Service users have a care plan that have their needs clearly stated. Some areas of health and safety have improved. There have been weekly checks on water temperature throughout the home. Staff reported they have regular supervision every two months.

What the care home could do better:

The home must improve the environment by replacing the carpet to one of the service user bedroom to make it nice and homely for the service user. The flooring to the toilet downstairs must be replaced to ensure it is clean and hygienic for service users. The kitchen flooring next to the doorway must be repaired to minimise health and safety risks to staff and service users.The home must improve the supervision arrangements for staff to ensure that staff will be adequately supported in all areas of their work. The home must also revise and update the complaints policy and other records.

CARE HOMES FOR OLDER PEOPLE Copperfield House 13 Worple Road Epsom Surrey KT18 5EP Lead Inspector Mr D Ramdas Unannounced 12th May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Copperfield House Address 13 Worple Road Epsom Surrey KT18 5EP 01372 726725 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Haroon Chaumoo Mr Haroon Chaumoo Care Home 16 Category(ies) of DE(E) - Dementia over 65 (2) registration, with number of places MD(E) - Mental Dissorder over 65 (2) OP - Old Age (14) Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 5. Up to two of the service users may be in the category DE(E) or MD(E) Date of last inspection 26th October 2004 Brief Description of the Service: Copperfield House is located in a residential road in Epsom, Surrey. It is close to the town centre and all the local amenities. The home provides accommodation for sixteen service users who are old and have a past or present mental disorder. Accommodation is provided in single rooms some of which have en-suite facilities. The accommodation is on two floors. There is a large lounge, dining area and conservatory which overlooks a well maintained garden to the rear of the property. There is a spacious kitchen, adequate bathing, washing and laundering facilities. Parking is available to the front of the property. Next door to the property is the Epsom Bowling Club. Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unnanounced inspection carried out by one inspector over 5.5 hours. A full tour of the premises took place, staff and service users were spoken to and care records and other documents were inspected. Six staff, the hairdresser, the painter and decorator, and five service users were spoken to. What the service does well: What has improved since the last inspection? What they could do better: The home must improve the environment by replacing the carpet to one of the service user bedroom to make it nice and homely for the service user. The flooring to the toilet downstairs must be replaced to ensure it is clean and hygienic for service users. The kitchen flooring next to the doorway must be repaired to minimise health and safety risks to staff and service users. Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 6 The home must improve the supervision arrangements for staff to ensure that staff will be adequately supported in all areas of their work. The home must also revise and update the complaints policy and other records. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3. Service users and prospective service users were provided with sufficient information to make an informed decision about admission to the home. Some information was in need of being updated. The system for the assessment of service users is good ensuring that the home is able to meet service users’ needs. EVIDENCE: The home was found to have a Statement of Purpose that contained information about how the home operated. The Statement of Purpose was dated April 2002. Some of the information in the Statement of Purpose needed to be updated, such as the complaints section. The home had a brochure that summarised the information contained in the Statement of Purpose. The information contained in the brochure was well written and clearly presented. The inspector advised the manager, he should add a section on complaints. The home had one vacancy. The manager stated, he had a request for an admission to the home but he had declined the admission because the home would not be able to meet the assessed needs. Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10 There is clear consistent care planning in place to adequately provide staff with the information they need to satisfactorily meet service users needs. EVIDENCE: Service user care needs were appropriately met. The inspector found one care plan to contain, an assessment covering physical, behavioural and mental health needs, risk assessments, strength and need assessments, a Waterlow pressure area assessment and nutritional screening assessment. The care plan had a care assessment record sheet that was used by staff to record actions taken and outcomes based on the service user care plan. The manager stated, one service user had problems with continence and was referred to the NHS continence advisor. The inspector found this was documented in the care assessment record sheet. It was noted the Care Plan was last reviewed on the 1st February 05. The inspector observed staff to respect the privacy and dignity of service users. Staff had been observed by the inspector to address service users by their preferred names. During the inspection the manager was observed to knock on service users bedroom doors and sought permission before entering their bedrooms. When interviewed staff stated, the standard of care was good. One service user stated, she had been at the home for ten years and during that time she had been well looked after by staff. Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: This area was not assessed as part of the inspection. Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18 The home has a complaints system that is understood by staff and there is evidence that some service users are able to use the system to get their views listened to and acted upon. EVIDENCE: The home had a complaints procedure and a complaints book. The procedure was kept in the Policies and Procedures file in the office. The manager stated, staff had been informed of the complaints procedure and that this had been given to relatives, service users and other professionals. The home also had a whistle blowing policy. During an interview with the inspector, staff stated they were made aware of the complaint procedure and the whistle blowing procedure during their induction. One of the staff files sampled indicated that the complaint procedure and the whistle blowing procedure had been discussed. The induction record had been signed by the manager but not by the employee. It had not been dated. The manager stated, there had been no complaints. The inspector noted no entries were made in the complaints book. The inspector advised the manager that the complaints procedure should be reviewed and updated. The procedure must make it clear that a complaint could be made to the Commission at any stage should a complainant wish to do so. The manager agreed to review and update the procedure. One service user stated, she would make any complaints to (Harry), the manager. Another service user remarked, ‘if things were bad I would complain it would be beneficial to the firm.’ Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: The inspector observed the home was clean, hygienic and free of mal odour. Toilet and bathroom areas were found to be clean. The standard of décor was generally good. The lounge and dining areas were pleasant. The lounge had a piano, television, games, flowers and ornaments and the dining area had dining tables that were covered in attractive tablecloths. The manager stated the dining furniture was replaced a year ago. The carpets were clean and generally of a good standard. Heating and lighting was adequate. Bedrooms were found to be well presented and personalised. The home had an aid call system in place. One service user had family photographs, a radio, flowers, ornaments and posters in her bedroom. During an interview a service user stated, she could see the sunset from her bedroom. She remarked, her bedroom was comfortable and it had lovely curtains. The gardens were well maintained, private and secure. It had plants, flowers, shrubs and also wheelchair access. Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 13 On the day of the inspection, the inspector was shown bedroom 8 that was being painted and decorated. The manager stated, this was part of ongoing refurbishment work to upgrade the environment. The inspector pointed out to the manager that the carpets in bedroom 1 were worn and threadbare and should be replaced. The flooring in the downstairs toilet next to the lift should be replaced and the flooring in the kitchen by the doorway was in need of repair. Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 The standard of vetting and recruitment practices are good with appropriate checks being carried out in order to protect service users. EVIDENCE: The inspector checked a staff recruitment file. It contained an application form, two written references, a job description, terms and conditions and an enhanced CRB disclosure. No photograph of the employee was found on file. The file also had induction training records and information on other courses attended by the employee such as the protection of vulnerable adults training. The file was securely and confidentially stored in a locked cabinet in the office. Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,36 Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. The arrangement for staff supervision must be improved to ensure staff supervision covers all aspects of practice. EVIDENCE: The manager was asked about his approach to the management of the home. The manager stated, he had a participative style. He commented, he would consult with staff and service users before he made management decisions. The inspector had a meeting with staff. They stated, the manager was approachable and supportive. They also stated they worked well together under the manager’s leadership. When they were faced with difficulties the manager would help them. They also stated that this had resulted in a good standard of care. The inspector met with a service user who stated, staff were very good on good days and had very few bad days. The inspector found no formal procedure for the supervision of staff. There was evidence that Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 16 supervision had taken place but it did not cover all aspects of work. The manager agreed that a supervision policy was required. Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 2 3 x STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x 3 x x x 2 x x Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 18 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard NMS -1 Regulation 4(1)(c) Requirement The registered person must ensure that the Statement of Purpose is updated to reflect arrangements made for dealing with complaints. The registered person must keep the service user plan under review and ensure it is reviewed monthly. The registered person must ensure that the complaints procedure is updated to state that a complaint can be made to the Commission at any stage should the complainant wish to do so. The registered person must ensure that all persons working in the home have a recent photograph which is to be kept in the recruitment file as proof of identity. The registered person must ensure persons working at the care home are appropriately supervised and that supervision arrangements be formalised by having a supervision policy. The registered person must ensure that the carpet in bedroom 1 is replaced. The Timescale for action 01.06.05 2. NMS - 7 15(2)(b) 01.06.05 3. NMS -16 22(1) 01.07.05 4. NMS- 29 Schedule 2 19(4)(i) 01.08.05 5. NMS- 35 18(2)(a) 01.08.05 6. NMS- 24 16(2)(c) 01.08.05 Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 19 7. NMS - 37 17(3)(a) flooring in the downstairs toilet next to the lift must be replaced and the flooring in the kitchen next to the doorway must be fixed. The registered person must ensure that all future induction records are signed and dated by the employee as well as the supervisor so as to reflect agreement between the employee and the supervisor. 01. 06. 05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 20 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Copperfield House H58_s13609_Copperfield House_v220520_120505_stage4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!